HospitalInspections.org

Based on document review, video review, medical record review and staff (EMP) interview it was revealed the hospital failed to follow their fall assessment policy to ensure the safety of one (1) of ten (10) (patient #2) medical records reviewed. The failure to assess, document and follow the policy for falls has the potential to adversely affect all patients who experience a fall.

Findings include:

A document review of the hospital policy entitled "Fall Prevention and Management Program," last revision/review date 10/2/19 revealed in part: "If the patient falls: ...Take vital signs ...Notify provider ...Notify Nurse Manager/Nurse Supervisor/Chief Nurse Executive ...The following must be completed once the patient's immediate needs are met: ...Document specific facts in the patient's medical record ...Complete an updated [hospital name] Fall Assessment/Reassessment ..."

1. A review of video footage for 10/26/21 from 8:14:09 a.m. to 8:16:43 a.m. conducted on 12/6/21 at 2:42 p.m. revealed EMP #1 came out of the nurse's station and charged at patient #1. EMP #1 extended their arms and made contact with patient #1's shoulders pushing patient #1 back against the wall. Patient #2 was standing in the hall at that time and was pushed by EMP #1 and patient #1 which caused patient #2 to fall to the floor. Patient #2 was seen lying supine on the floor until assisted to a standing position by two (2) staff members.

2. A review of patient #2's medical record revealed there was no documentation about the fall. There were no vital signs documented, no notification to the provider, no documentation the nursing leadership was notified and no fall assessment/reassessment documented.

3. An interview conducted with EMP #5 on 12/7/21 at 1:42 p.m. revealed they were not notified of the event or the patient fall until the Sunday after it occurred.

4. An interview conducted with EMP #6 on 12/7/21 at 1:53 p.m. revealed they were not notified of the event or the patient fall until the Sunday after it occurred.

5. An interview conducted with EMP #5 on 12/7/21 at 1:42 p.m. revealed they agreed with the above findings